dutton chapter 24 the temporomandibular joint

8/18/2019 Dutton Chapter 24 the Temporomandibular Joint

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Chapter 24Chapter 24

The Temporomandibular Joint The Temporomandibular Joint


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OverviewOverview

The stomatognathic system comprises the The stomatognathic system comprises the

temporomandibular joint (TMJ), thetemporomandibular joint (TMJ), the

masticatory systems, and the relatedmasticatory systems, and the related

organs and tissues such as the salivaryorgans and tissues such as the salivary

glandsglands

Due to the proximity of this system withDue to the proximity of this system with

the other structures of the head and nec,the other structures of the head and nec,

an intimate relationship existsan intimate relationship exists

This relationship begins in the early stages This relationship begins in the early stages

of human embryologyof human embryology


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BonesBones

MandibleMandible

MaxillaMaxilla

!ygomatic arch!ygomatic arch

Temporal bone Temporal bone


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TemporomandibularTemporomandibular

Joint Joint The articular surfaces of theThe articular surfaces of the

temporomandibular oint are linedtemporomandibular oint are lined

b! "brous tissue # this re$ects theb! "brous tissue # this re$ects thedevelopment of the ointdevelopment of the oint

%nli&e all other s!novial oints%nli&e all other s!novial ointswhose articular surfaces developwhose articular surfaces develop

endochondrall! and are thereforeendochondrall! and are thereforelined b! h!aline cartila'e( thelined b! h!aline cartila'e( thetemporomandibular oint developstemporomandibular oint developsin membranein membrane


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)ntra#articular *isc)ntra#articular *isc

"ibrous in structure"ibrous in structure

Divides the joint cavity into twoDivides the joint cavity into two

regionsregions Thinnest centrally Thinnest centrally

#ttaches anteriorly to the lateral#ttaches anteriorly to the lateral

pterygoidpterygoid #ttaches posteriorly to the condyle#ttaches posteriorly to the condyle


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Joint Capsule Joint Capsule

$apsular ligaments % &bers only$apsular ligaments % &bers only

pass between the temporal bonepass between the temporal bone

and mandible on the lateral sideand mandible on the lateral side

'ntrinsic ligaments % short &bers'ntrinsic ligaments % short &bers

which pass from the bone to thewhich pass from the bone to the

intraarticular discintraarticular disc


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+i'amentous support+i'amentous support

ateral TMJ ligamentateral TMJ ligament

*tylomandibular ligament*tylomandibular ligament


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MusclesMuscles

ateral pterygoidateral pterygoid+ rigin %rigin %

-pper head arises from the infratemporal surface of the-pper head arises from the infratemporal surface of thegreater wing of the sphenoidgreater wing of the sphenoid

ower head arises from the lateral surface of the lateralower head arises from the lateral surface of the lateralpterygoid platepterygoid plate

+ 'nsertion The anterior aspect of the nec of the'nsertion The anterior aspect of the nec of themandibular condyle and capsule of the TMJmandibular condyle and capsule of the TMJ

+ 'nnervation # branch of the mandibular division of the'nnervation # branch of the mandibular division of thetrigeminal nervetrigeminal nerve

+ "unction"unction -pper head involved mainly with chewing, and functions to-pper head involved mainly with chewing, and functions to

anteriorly rotate the disc on the condyle during the closinganteriorly rotate the disc on the condyle during the closingmovementmovement

ower head exerts an anterior, lateral, and inferior pull onower head exerts an anterior, lateral, and inferior pull onthe mandible, thereby opening the jaw, protruding thethe mandible, thereby opening the jaw, protruding themandible, and deviating the mandible to the opposite sidemandible, and deviating the mandible to the opposite side


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MusclesMuscles

Medial pterygoidMedial pterygoid+ rigin Deep origin situated on the medialrigin Deep origin situated on the medial

aspect of the mandibular ramusaspect of the mandibular ramus

+ 'nsertion The inferior and posterior aspects of'nsertion The inferior and posterior aspects ofthe medial subsurface of the ramus and anglethe medial subsurface of the ramus and angleof the mandibleof the mandible

+ 'nnervation # branch of the mandibular'nnervation # branch of the mandibulardivision of the trigeminal nervedivision of the trigeminal nerve

+ "unction .oring bilaterally assists in"unction .oring bilaterally assists inmouth closing/ .oring unilaterally %mouth closing/ .oring unilaterally %deviation of the mandible toward the oppositedeviation of the mandible toward the oppositesideside


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MusclesMuscles

Masseter twolayered 0uadrilateral shapedMasseter twolayered 0uadrilateral shapedmuscle/muscle/% riginrigin

The super&cial portion arises from the anterior twothirds of the The super&cial portion arises from the anterior twothirds of thelower border of the 1ygomatic archlower border of the 1ygomatic arch

The deep portion arises from the medial surface of the 1ygomatic The deep portion arises from the medial surface of the 1ygomaticarch/arch/

% 'nsertion n the lateral surface of the coronoid process'nsertion n the lateral surface of the coronoid processof the mandible, upper half of the ramus and angle of theof the mandible, upper half of the ramus and angle of themandiblemandible

% 'nnervation # branch of the mandibular division of the'nnervation # branch of the mandibular division of thetrigeminal nervetrigeminal nerve

% "unction The major function of the masseter is to elevate"unction The major function of the masseter is to elevatethe mandible, thereby occluding the teeth duringthe mandible, thereby occluding the teeth duringmastication/mastication/


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MusclesMuscles

Tempororalis Tempororalis+ rigin The 2oor of the temporal fossa andrigin The 2oor of the temporal fossa and

temporal fasciatemporal fascia

+ 'nsertion n the anterior border of the'nsertion n the anterior border of thecoronoid process and anterior border of thecoronoid process and anterior border of theramus of the mandibleramus of the mandible

+ 'nnervation # branch of the mandibular'nnervation # branch of the mandibular

division of the trigeminal nervedivision of the trigeminal nerve+ "unction assists with mouth closing3side"unction assists with mouth closing3side

toside grinding of the teeth/ #lso providestoside grinding of the teeth/ #lso providesa good deal of stability to the jointa good deal of stability to the joint


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MusclesMuscles

*i'astric*i'astric% Ori'in # The posterior bell! arises from theOri'in # The posterior bell! arises from the

mastoid( or di'astric( notch immediatel! behindmastoid( or di'astric( notch immediatel! behindthe mastoid process of the temporal bone,the mastoid process of the temporal bone,

% )nsertion # The posterior bell! passes downwards)nsertion # The posterior bell! passes downwardsand forwards towards the h!oid bone where itand forwards towards the h!oid bone where itbecomes the intermediate di'astric tendon andbecomes the intermediate di'astric tendon and

oins with the anterior bell!, oins with the anterior bell!,% Nerve -uppl! # derived from the di'astric branch ofNerve -uppl! # derived from the di'astric branch of

the facial nerve,the facial nerve,

% .asculature # arterial blood suppl! from the.asculature # arterial blood suppl! from theposterior auricular and occipital arteries,posterior auricular and occipital arteries,% Action # The muscle depresses the mandible andAction # The muscle depresses the mandible and

can elevate the h!oid bone, The posterior belliescan elevate the h!oid bone, The posterior belliesact in unison and are particularl! active durin'act in unison and are particularl! active durin'swallowin' and chewin',swallowin' and chewin',


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B)OM/C0AN)C-B)OM/C0AN)C-


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BiomechanicsBiomechanics

TMJ motions involve a TMJ motions involve acombination of rolls and glides ofcombination of rolls and glides of

the mandibular head and discthe mandibular head and disc #ll TMJ motions involve all or#ll TMJ motions involve all or

some of the following4some of the following4%

#nterior3posterior glide#nterior3posterior glide% Medial3lateral glideMedial3lateral glide

% 'nferior3posterior glide'nferior3posterior glide


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Openin' and closin'Openin' and closin'

Mouth openingMouth opening% #nterior glide#nterior glide

% ateral glideateral glide% 'nferior glide'nferior glide

Mouth closingMouth closing

% 5osterior glide5osterior glide% Medial glideMedial glide

% *uperior glide*uperior glide


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+ateral *eviation+ateral *eviation

$ontralateral deviation$ontralateral deviation

% #nterior, inferior and lateral glide of#nterior, inferior and lateral glide of

the mandibular head and discthe mandibular head and disc 'psilateral deviation'psilateral deviation

% 5osterior, superior and medial glide5osterior, superior and medial glide

of the mandibular head and discof the mandibular head and disc


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1rotrusion and1rotrusion and

etrusionetrusion 5rotrusion5rotrusion

% #nterior, inferior and lateral glide of#nterior, inferior and lateral glide of

the mandibular head and discthe mandibular head and disc 6etrusion6etrusion

% 5osterior, superior and medial glide5osterior, superior and medial glide



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/3AM)NAT)ON/3AM)NAT)ON


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/amination/amination

#s with any other synovial joint,#s with any other synovial joint,

there are a number of possiblethere are a number of possible

causes3scenarios4causes3scenarios4% ocal causeocal cause

% 6eferred cause6eferred cause

% oss of motion with or without painoss of motion with or without pain% 7xcessive motion with or without7xcessive motion with or without

painpain


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0istor!0istor!

There are three cardinal features of There are three cardinal features oftemporomandibular disorders (TMD)4temporomandibular disorders (TMD)4% 6estricted jaw function (intermittent or6estricted jaw function (intermittent or

progressive)progressive)% Joint noise (signi&cant if associated with other Joint noise (signi&cant if associated with other

factors)factors)

% rofacial painrofacial pain ((5ain that is centered immediately5ain that is centered immediatelyin front of the tragus of the ear and projects toin front of the tragus of the ear and projects to

the ear, temple, chee, and along the mandible isthe ear, temple, chee, and along the mandible ishighlydiagnostic for TMD)highlydiagnostic for TMD)

't is important to observe the patient8s't is important to observe the patient8smouth while they talmouth while they tal


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0istor!0istor!

#ttempt to determine a speci&c#ttempt to determine a speci&cmechanism4mechanism4% Trauma (including surgery % 9controlled Trauma (including surgery % 9controlled

trauma:)trauma:)% 5osture5osture

% 7motional factors7motional factors

% 5arafunctional habits (chee biting, nail5arafunctional habits (chee biting, nail

biting, pencil chewing, teeth clenchingbiting, pencil chewing, teeth clenching(day), bruxism (night))(day), bruxism (night))

% *ymptomprovoing motions of the TMJ or*ymptomprovoing motions of the TMJ orneighboring joint(s)neighboring joint(s)


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0istor!0istor!

The patient8s past dental and The patient8s past dental and

orthodontic historyorthodontic history

.hether the patient has.hether the patient hasexperienced any 9locing: of theexperienced any 9locing: of the

jaw jaw

.hether the symptoms are.hether the symptoms areimproving or worseningimproving or worsening


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0istor!0istor!

*ystems review*ystems review% 5ain or dysfunction in the orofacial5ain or dysfunction in the orofacial

region can often be due to nonregion can often be due to nonmusculoseletal causes4musculoseletal causes4 tolaryngologic diseasetolaryngologic disease ;eurologic disease;eurologic disease


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ObservationObservation

The forward head posture is fre0uently The forward head posture is fre0uently

associated with TMDassociated with TMD=//try it=//try it

# lateral deviation of the jaw, evidenced# lateral deviation of the jaw, evidencedby a malalignment or malocclusion ofby a malalignment or malocclusion of

the upper and lower teeth, may causethe upper and lower teeth, may cause

an adaptive shortening of thean adaptive shortening of the

mastication muscles on one side, and amastication muscles on one side, and alengthening of the mastication muscleslengthening of the mastication muscles

on the contralateral side/on the contralateral side/


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ObservationObservation

$avities, wear patterns, and restored and$avities, wear patterns, and restored andmissing teeth should be notedmissing teeth should be noted% Tooth wear and fracture are often destructive signs Tooth wear and fracture are often destructive signs

of parafunctional habitsof parafunctional habits The rest position of the TMJ should be noted The rest position of the TMJ should be noted

% The rest position of the TMJ is determined by The rest position of the TMJ is determined bygently placing the little &nger with the palmargently placing the little &nger with the palmarportion facing anteriorly into the external auditoryportion facing anteriorly into the external auditory

meatus/ "rom an open mouth position, the patientmeatus/ "rom an open mouth position, the patientis ased to slowly close their mouth/ #t the pointis ased to slowly close their mouth/ #t the pointof the resting position, the patient8s mandibularof the resting position, the patient8s mandibularheads should be felt to gently touch the &nger/heads should be felt to gently touch the &nger/


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an'e of Motionan'e of Motion

The range of motion of the The range of motion of the

cervical spine, craniovertebralcervical spine, craniovertebral

joints and the shoulders should be joints and the shoulders should beassessedassessed

The range of motion of the nec The range of motion of the nec

and jaw should then be assessed4and jaw should then be assessed4% #ctive range of motion with passive#ctive range of motion with passive

overpressure to assess the end feel/overpressure to assess the end feel/


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an'e of Motionan'e of Motion

#ll movements should be smooth#ll movements should be smooth

and without noise or painand without noise or pain

% 'f pain occurs, a determination should'f pain occurs, a determination shouldbe made as to where in the range thebe made as to where in the range the

pain occurs, and the location of the painpain occurs, and the location of the pain

The type and temporal se0uence of The type and temporal se0uence of

joint clicing can provide the joint clicing can provide theclinician with informationclinician with information


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Joint Noise Joint Noise

6eciprocal clicing is de&ned as6eciprocal clicing is de&ned as

clicing that occurs during openingclicing that occurs during opening

and again during closing/and again during closing/% 7arly clicing usually indicates a small7arly clicing usually indicates a smallanterior displacementanterior displacement

% ate clicing usually indicates that the discate clicing usually indicates that the disc

has been further displacedhas been further displaced ften due to articular hypermobility, and isften due to articular hypermobility, and is

accompanied by a deviation of the jaw towardaccompanied by a deviation of the jaw toward

the contralateral side/the contralateral side/


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Mouth Openin'Mouth Openin'

Mouth opening is the most revealing andMouth opening is the most revealing anddiagnostic movement for TMDdiagnostic movement for TMD

;ormal motion tested using nucle test;ormal motion tested using nucle test

(approximately a twothreenucle width of the(approximately a twothreenucle width of thenondominant hand) or more objectively bynondominant hand) or more objectively bymeasuring (closer to >? mm)measuring (closer to >? mm)% # limited opening of the jaw may indicate joint# limited opening of the jaw may indicate joint

hypomobility, muscle tightness, or the presence ofhypomobility, muscle tightness, or the presence oftrigger points within the elevator muscles4 thetrigger points within the elevator muscles4 the

temporalis, masseter and medial pterygoidtemporalis, masseter and medial pterygoid% ther causes of diminished mandibular opening includether causes of diminished mandibular opening include

structural disorders of the TMJ, such as anylosis,structural disorders of the TMJ, such as anylosis,internal derangements, and gross osteoarthritisinternal derangements, and gross osteoarthritis


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C and - CurvesC and - Curves

# @$pattern8 of motion occurs if the# @$pattern8 of motion occurs if thehypomobility is due to internal derangementhypomobility is due to internal derangement% The mandible deviates toward the involved side in the The mandible deviates toward the involved side in the

midrange of opening before returning to normal/midrange of opening before returning to normal/ #n @*pattern8 of movement while opening the#n @*pattern8 of movement while opening the

mouth may indicate a muscle imbalance/ #n arcmouth may indicate a muscle imbalance/ #n arcmay indicate a muscle imbalancemay indicate a muscle imbalance

ateral excursion of the mandible with mouthateral excursion of the mandible with mouth

opening implicates contralateral structures suchopening implicates contralateral structures suchas the contralateral disc, masseter, temporalis,as the contralateral disc, masseter, temporalis,lateral pterygoid, or the lateral ligamentslateral pterygoid, or the lateral ligaments


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1alpation1alpation

5alpation of the TMJ is used to5alpation of the TMJ is used to

assess tenderness, sinassess tenderness, sin

temperature, muscle tone, swelling,temperature, muscle tone, swelling,sin moisture, and the location ofsin moisture, and the location of

trigger pointstrigger points

% 5alpations of the lateral and posterior5alpations of the lateral and posterior

aspects of the temporomandibularaspects of the temporomandibular joints are performed bilaterally and joints are performed bilaterally and

simultaneouslysimultaneously


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-tren'th Testin'-tren'th Testin'

't is important to be able to't is important to be able to

selectively stress the muscles ofselectively stress the muscles of

mastication and facial expressionmastication and facial expressionto determine whether they areto determine whether they are

implicated in the symptomsimplicated in the symptoms


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+i'ament -tress Tests+i'ament -tress Tests

The ligament stress tests assess the The ligament stress tests assess the

integrity of the capsule and ligamentsintegrity of the capsule and ligaments

% 5ositive &ndings include excessive5ositive &ndings include excessivemotion as compared to the other side, ormotion as compared to the other side, or

painpain

Two structures are primarily tested4 Two structures are primarily tested4

% Temporomandibular ligament Temporomandibular ligament

% Joint capsule Joint capsule


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1assive Articular1assive Articular

Mobilit!Mobilit! The passive articular mobility tests assess the The passive articular mobility tests assess the

joint glides and the end feels joint glides and the end feels% "indings are compared with each side"indings are compared with each side

% 5ain or a restricted glide are positive &ndings and5ain or a restricted glide are positive &ndings andmay indicate articular involvement or a capsularmay indicate articular involvement or a capsularrestriction/restriction/

't is important to chec the speci&c glides that't is important to chec the speci&c glides thatare related to the loss of active motion/ "orare related to the loss of active motion/ "or

example, if a patient demonstratedexample, if a patient demonstrateddiminished mouth opening mouth, thediminished mouth opening mouth, thecombined anterior, inferior, and lateral glide iscombined anterior, inferior, and lateral glide isassessed for each joint/assessed for each joint/


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Articular 'lidesArticular 'lides

Mouth openin'( contralateralMouth openin'( contralateral

deviation( and protrusion all involvedeviation( and protrusion all involve

an anterior( inferior and lateral 'lidean anterior( inferior and lateral 'lide


Mouth closin'( ipsilateral deviation(Mouth closin'( ipsilateral deviation(

and retrusion all involve anand retrusion all involve an

posterior( superior and medial 'lideposterior( superior and medial 'lideof the mandibular head and discof the mandibular head and disc


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ConclusionsConclusions

'f the joint glides are normal % the joint is'f the joint glides are normal % the joint isA A % $hec ligaments and surrounding tissues$hec ligaments and surrounding tissues

'f the joint glides are restricted, the cause'f the joint glides are restricted, the causecould indicate a joint3joint capsulecould indicate a joint3joint capsulerestriction, a ligamentous adhesion orrestriction, a ligamentous adhesion oradaptive shortening of the surroundingadaptive shortening of the surrounding

tissues % need to mobili1e the oBendingtissues % need to mobili1e the oBending joint and reassess joint and reassess The intervention should always match the The intervention should always match the

diagnosisCCdiagnosisCC


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Articular testsArticular tests

Dynamic loadingDynamic loading% The patient bites forcefully on a cotton roll The patient bites forcefully on a cotton roll

or tongue depressor on one side/ Thisor tongue depressor on one side/ This

maneuver loads the contralateral TMJ/maneuver loads the contralateral TMJ/ Joint compression Joint compression

% The clinician, standing behind the seated or The clinician, standing behind the seated orsupine patient, places the &ngers of eachsupine patient, places the &ngers of each

hand under each side of the mandible, withhand under each side of the mandible, withthe thumbs resting on the ramus/ Thethe thumbs resting on the ramus/ Themandible is then tipped posteriorly andmandible is then tipped posteriorly andinferiorly to compress the joint surfacesinferiorly to compress the joint surfaces


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Neurolo'ical testsNeurolo'ical tests

Trigeminal sensation Trigeminal sensation

Trigeminal re2ex Trigeminal re2ex


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)NT/./NT)ON)NT/./NT)ON


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)ntervention)ntervention

ased on4ased on4

% *tage of healing/*tage of healing/ $hronic TMD pain$hronic TMD pain

often occurs because of secondaryoften occurs because of secondaryfactors4factors4 # &xed head forward posture# &xed head forward posture

#bnormal stress levels#bnormal stress levels

DepressionDepression ral parafunctional habitsral parafunctional habits

% *tructure involved*tructure involved


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Acute -ta'eAcute -ta'e

The acute patient typically The acute patient typically

demonstrates4demonstrates4

% # capsular pattern of restriction (decreased# capsular pattern of restriction (decreased

ipsilateral opening and lateral deviation toipsilateral opening and lateral deviation to

the contralateral side), with pain andthe contralateral side), with pain and

tenderness on the same sidetenderness on the same side

There may be associated ligamentous There may be associated ligamentous

damage (positive stress tests), ordamage (positive stress tests), ormuscular damage (positive strengthmuscular damage (positive strength

tests)tests)


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Acute -ta'eAcute -ta'e

The usual methods of decreasing The usual methods of decreasingin2ammation are recommended4in2ammation are recommended456'$7M7M56'$7M7M

% 11rotectionrotection% estest

% ))cece

% CCompressionompression

% //levationElevationE% MManual therapyanual therapy

% //arly motionarly motion

% MMedicationsedications


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TMJ /ercisesTMJ /ercises

#cute stage4#cute stage4

% 99FxF: exercise protocol of 6ocabadoFxF: exercise protocol of 6ocabado

% $or exercise$or exercise% Tongue positioning during mouth Tongue positioning during mouth

opening and closingopening and closing


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TMJ /ercisesTMJ /ercises

"unctional *tage4"unctional *tage4

% *trengthening exercises for the*trengthening exercises for the

cervicothoracic stabili1ers, and thecervicothoracic stabili1ers, and thescapular stabili1ersscapular stabili1ers

% *tretching exercises for the*tretching exercises for the

scalenes, trape1ius, pectoralisscalenes, trape1ius, pectoralis

minor, and levator scapulaeG and theminor, and levator scapulaeG and the

suboccipital extensorssuboccipital extensors


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0ome0ome

5Automobili6ation75Automobili6ation7/ercises/ercises Mouth opening exerciseMouth opening exercise Tongue depressor exercise Tongue depressor exercise

Toothpic exercise Toothpic exercise

Distraction mobili1ationDistraction mobili1ation


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8unctional 5Chronic78unctional 5Chronic7

-ta'e-ta'e 5ostural and patient education should5ostural and patient education should

form the cornerstone of any plan of careform the cornerstone of any plan of care

for TMDfor TMD 5sychotherapy referral5sychotherapy referral

Manual techni0uesManual techni0ues

7xercise7xercise

Thermal and electrotherapeutic Thermal and electrotherapeuticmodalitiesmodalities

Trigger point therapy Trigger point therapy

dutton chapter 24 the temporomandibular joint

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